Tear duct surgery from the outside (Toti surgery or dacryocystorhinostomy) is a method for the surgical treatment of blocked tear ducts in the eye (tear duct stenosis). If the draining tear ducts are blocked, this can lead to an "overflowing" eye or inflammation of the tear ducts.
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Tears serve to moisturize and nourish the cornea and to wash out the eyes if a foreign body gets into them.
The lacrimal gland is located in the upper-outer region of the eye socket outside the eye. It constantly produces tear fluid, which flows over the cornea. Two small openings (lacrimal puncta) on the upper and lower eyelid (nasal side) eventually collect the fluid.
The lacrimal puncta merge into the two tear ducts, which flow together into the lacrimal sac. From here, the lacrimal sac merges into the nasal passage. The fluid passes through this into the nasal cavity, where it can drain away.
Lacrimal gland (a) and lacrimal ducts: b = upper lacrimal punctum. c = upper lacrimal duct. d = lacrimal sac. e = lower lacrimal duct. f = lower lacrimal duct. g = nasolacrimal duct
If this connection is blocked, the tear fluid cannot drain and the eye overflows. A blocked tear duct can therefore lead to severe inflammation.
The cause of lacrimal duct stenosis is not always known. The tear ducts may be narrowed or blocked. In small children, the Hasner membrane often does not regress correctly after birth and blocks the tear ducts. Other common causes are inflammation or injury to the tear ducts.
Patients notice a stenosis due to their eyes being very watery or overflowing. Those affected also complain of blurred vision and an excess of tear fluid.
This is initially more noticeable when reading or driving. They usually do not feel any pain at first. This changes when the tear duct or eyelid becomes inflamed due to the stenosis .
It is not only aesthetic reasons and unpleasant symptoms that speak in favor of prompt treatment. In most cases, doctors treat lacrimal duct stenosis with lacrimal duct surgery.
The procedure can be performed as follows:
There are various methods of tear duct surgery, depending on the cause. The exact location of the blockage plays a role in planning the procedure.
If the cause of the lacrimal duct stenosis is unknown, the choice of surgical method is not always easy. The treating physician must take this into account when diagnosing a stenosis.
If you suspect a stenosis of the tear ducts due to the symptoms, you should consult an ophthalmologist immediately. During the anamnesis, you will discuss your medical history with the doctor and how long the symptoms have been present. He or she will also discuss possible external causes.
Your doctor will use various diagnostic procedures to determine whether there is an obstruction or narrowing of the tear duct. Or whether the severe watering of the eye has another cause.
The treating doctor will also determine where the blockage or narrowing is located. Various methods are also available for this. To diagnose lacrimal duct stenosis, your doctor will use an ultrasound and X-ray examination.
An eye test, external examination of the eye and lacrimal duct irrigation round off the diagnosis and examinations. Rinsing the tear ducts plays a central role in the preliminary examinations. This gives a good chance of localizing the stenosis of the tear duct.
The doctor then decides which type of procedure is appropriate:
To avoid the risk of severe bleeding during the operation, you should stop taking anticoagulant medication before the procedure.
The aim of lacrimal duct surgery is to establish a normal and healthy outflow of tear fluid from the surface of the eye into the nasal cavity. Various procedures are available for this purpose. The doctor will clarify which procedure is suitable for the patient during the preliminary examination. It is also possible to change methods during the procedure in order to achieve the best possible result.
Tear duct surgery, whether internal or external, outpatient or inpatient, is always performed under general anesthesia.
The procedures are:
In children, lacrimal duct irrigation and probing is usually sufficient. The doctor opens the persistent Hasner's membrane by means of positive pressure irrigation.
In some cases, subsequent lacrimal duct splinting with silicone probes is necessary, which the doctor removes after three months. The use of a tube prevents the tear duct from clogging (again).
Tear duct intubation is the simplest and gentlest method of tear duct surgery. It is not suitable for every type of stenosis.
Microdrillplasty (MDP) is another procedure used to open the stenosis. This is done using a fine drilling device or a laser (laser dacryoplasty (LDP)). These procedures are mostly used for endoscopic lacrimal duct surgery.
Doctors use a Toti operation if there is inflammation of the lacrimal sac ( known as dacryocystitis ). It is also used for most injuries to the tear ducts to prevent the ducts from growing together incorrectly, resulting in narrowing and occlusion, which looks like a stenosis.
As the damaged tissue could grow together incorrectly after an injury, doctors perform lacrimal duct surgery. The doctors push the tissue back into its original position and close it.
They make a fine incision in the nasal area (in the immediate vicinity of the corner of the eye). They then open the lacrimal sac and the bones to the nasal cavity. They usually drill it open to create an artificial opening.
They then stitch the lacrimal sac and nasal mucosa together to create a drainage channel. In most cases, they also insert fine silicone probes for three months. These prevent renewed scarring and thus the closure of the tear ducts.
At the end of the operation, the skin is sutured. Doctors use very fine suture material that generally leaves no visible scars.
Further and special methods of lacrimal duct surgery can be used depending on the findings.
A stenosis can also be stretched using a balloon. If the stenosis keeps recurring, a Jones operation is necessary. This creates a widened connection to the nasal cavity, into which doctors insert a small tube made of sturdy plastic. Experts also call the small plastic tube a Jones tube or Metaireau tube.
Most severe stenoses can be repaired using the Jones method. The procedure is performed from the outside and is the last possible option.
Depending on the findings and type of lacrimal duct surgery, the inserted tube remains in the body for three months. Even if it is intended to temporarily widen a "normal" stenosis. Only in exceptional situations and with Jones tubes can the foreign body remain in the body for longer or permanently.
After lacrimal duct surgery, you will need to use antibiotic and decongestant eye drops for about two weeks as a prophylactic measure.
Your ophthalmologist will prescribe eye drops and/or eye ointment for the period afterlacrimal duct surgery @ megaflopp /AdobeStock
In addition, you should not blow your nose for the first few weeks after the operation. The pressure and the newly created pathway can cause air to enter the eyelid and cause it to swell massively.
Instead, you should only gently dab your nose or gently pull up the secretions.
If the tube slips out despite all caution, this is usually harmless. However, as it can impair the healing process, you should consult your ophthalmologist immediately. They can decide whether further lacrimal duct surgery is necessary to reposition the tube.
Good results can usually be achieved with lacrimal duct surgery. The heavy flow of tears from the eyes and other symptoms such as blurred vision improve and disappear completely.
However, stenosis may recur. Tear duct surgery from the outside is usually more promising than endoscopic tear duct surgery from the inside. However, endoscopic surgery is gentler.
The risks and side effects are slightly higher with Toti surgery than with the endoscopic procedure.
Common side effects are
Inflammation, on the other hand, occurs much less frequently. They are a serious risk that increases with a lack of caution.
Damage to the eyelids or the eye itself is very rare.
It is important that you have the lacrimal duct surgery performed in a specialized center.
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